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A nurse in the emergency department is caring for a 52-year-old male client experiencing chest pain. Below are the exhibits to guide your answer:

Exhibits

Complete the diagram by dragging from the choices below to specify:

The condition the client is most likely experiencing.

Two actions the nurse should take.

Two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition: Myocardial infarction.

2 actions:

Administer oxygen via nasal cannula 2 L/min,

Request a prescription for aspirin 325 mg.

2 parameters:

Vital signs,

Electrocardiogram (ECG) rhythm.

Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.

Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.

Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.

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Correct Answer is A

Explanation

Choice A rationale

Monitoring blood glucose levels more frequently is critical when a client with type 1 diabetes is taking prednisone, as corticosteroids can raise blood glucose levels and potentially cause hyperglycemia.

Choice B rationale

Increasing sodium intake is not recommended for clients with type 1 diabetes and is unrelated to the management of prednisone-induced hyperglycemia.

Choice C rationale

Stopping all other diabetes medications is inappropriate and can lead to uncontrolled blood glucose levels. Adjustments may be needed, but discontinuation is not advised without medical supervision.

Choice D rationale

Skipping meals to prevent hyperglycemia is not a safe practice for clients with type 1 diabetes. Maintaining a balanced diet and monitoring blood glucose levels is essential.

A. Attach a wrist band indicating the client's allergy. B. Notify the dietary department of the client's allergy. C. Ask the client if any other foods cause such a reaction. D. Notify the provider of the client's allergy.

Correct Answer is D

Explanation

Choice A rationale

Attaching a wristband indicating the client's allergy is a good practice, but it is not the priority action. The priority is to notify the provider to avoid any potential allergic reactions during the procedure.

Choice B rationale

Notifying the dietary department is not relevant in this context. The priority is to ensure the provider is aware of the allergy to prevent an adverse reaction during the cardiac catheterization.

Choice C rationale

Asking the client about other food allergies is important, but the priority action is to notify the provider immediately to ensure the safety of the client during the procedure.

Choice D rationale

Notifying the provider of the client's allergy is the priority action. This ensures that the provider can take necessary precautions to prevent an allergic reaction during the cardiac catheterization procedure.

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Naxlex Comprehensive Predictor Exams

A client diagnosed with type 1 diabetes is prescribed prednisone for acute exacerbation of inflammatory bowel disease.Which intervention should the nurse discuss with the client?

Correct Answer is A

Explanation

The nurse asks a client who is about to have a cardiac catheterization about any allergies.The client states, "I always get a rash when I eat shellfish.”. Which of the following is the priority nursing action?

Correct Answer is D

Explanation

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